Month: April 2016

A recent story about a spike in Sexually Transmitted Infections (STIs) in Alberta piqued my interest, not so much because of the increase, but the reaction to it. The Alberta Chief Medical Officer of Health, Dr. Karen Grimsrud, blamed “apps”: “We believe this is due to use of social media to set up sexual encounters,” she said, and added that social media tools are helping people communicate quickly to arrange anonymous sexual encounters. While I agree with her follow-up statement – that anonymous encounters make it difficult to contact people for testing and treatment – I cannot join her in blaming a social media platform for a complex social issue.

While it is true that apps make casual sexual relationships more accessible, you still have to make a decision about what’s going to happen – and how – whether you meet in a bar; or whether you meet online through a dating site or app. Human behaviour is complicated; and human sexual behaviour is especially complicated when it comes to risk-taking. Any sexual relationship, be it a one-time hook-up or longer term, requires clear communication. Consent – ongoing, affirmative consent about the sexual activities that will occur should be established; and the level of safety with which both people are comfortable should be negotiated. Should.

And yet, communication and negotiation are not always straightforward. The result is risky behaviour.

The social determinants of health influence risk-taking. Poverty, for example, is associated with increased risk-taking. In my city, one can map the curve of teen pregnancy and STIs through the poorer neighbourhoods. Internalized homophobia, current or previous abuse may also prevent a person’s ability to be assertive about safer sex because of low self-worth.

Most STIs show no symptoms. To be blunt, if you have had unprotected sexual activity, you need to be tested. But you will not necessarily get an HIV test for example, unless you specifically ask for it. That means you have to actually disclose your unsafe sexual practices. Bacterial infections can be cured with antibiotics, but viral infections, although treatable, generally stay in the body. The exception is Human Papillomavirus (HPV) which clears in the majority of cases.

Women may falsely believe they are protected because they have regular Pap tests. But they are unaware that the Pap only looks for unusual cells on the cervix: it does not test for STIs.

Men may avoid testing because they are afraid they will be swabbed for Chlamydia and gonorrhea; clinics generally do a urine test.

There is no test for (HPV) or a screening test for herpes. You have to show your bump or sore to a doctor. You may not even notice a sore on, around or inside the genitals, especially if it goes away.

Some people want testing so they can stop using barrier protection for vaginal or anal sex. One of the reasons for an increase in chlamydia among young heterosexuals is that he drops the condom before testing once she starts using the Pill.

After testing, a couple can negotiate the sexual activities they are willing to have without protection. If someone has a history of cold sores, for example (caused by herpes simplex virus – 1), they should tell their partner before offering unprotected oral sex. (In the absence of a sore, one can still transmit HSV-1.)

Public Health initiatives

After the first Alberta STI spike in 2013, they came up with sexgerms.com . “Plenty of syph” received a lot of attention, much of it negative. The site has since been revised. But it still refers, as do most educational materials, to “sex” rather than higher and lower risk sexual activities. Moreover, the assumption is that “sex” means penis in vagina intercourse. Skin-to-skin contact in the “boxer short area” is enough to spread HPV and HSV -1 and -2.

Since we’re not going to plastic wrap our entire bodies, there is always some risk involved.

But health authorities are not always realistic. Dr. James Talbot, former Chief MOH of Alberta interviewed during the 2015 STI spike called for:

no unprotected sex

abstinence

mutual monogamy

condoms

This is not a risk reduction strategy.

There is no point encouraging unrealistic, unattainable goals. In 30 years of clinic work, I can count a handful of people who used condoms for oral sex, most of whom were sex workers. So when I talked with men who had sex with men, I explained that if they were having multiple oral sex partners and not using condoms, they needed to be tested more frequently for syphilis, which could be treated and cured. This is a concrete way to prevent HIV transmission.

Older folks get frisky, too

The Current discussion touched on seniors and safer sex. The statistics for seniors are becoming alarming. Statistics show increases in incidents of syphilis, chlamydia and gonorrhea in adults 45-64. Alex McKay of SIECCAN mentioned an ongoing study of middle aged Canadians, indicating that condom use for this group is “staggeringly low”.

Older people may be even less able to communicate about STIs than teenagers or young adults. Heterosexuals may have used condoms in the old days for pregnancy protection, rather than out of concern for STIs. They may (erroneously) assume that a new sexual partner was monogamous during their former long-term relationship. They may also be learning the dating game the “hard” way. A 2010 study discovered that men who use erectile dysfunction drugs such as Viagra have higher rates of STIs in the year before and after use of these drugs.

Older women whose vaginas may have lost elasticity and the ability to lubricate may be at higher risk for STIs including HIV. Potential abrasions during vaginal intercourse may allow the entrance of viruses and bacteria. Prolonged vaginal intercourse with a Viagra inspired partner may not help either.

True prevention

Rather than app bashing or unrealistic expectations, let’s just apply good old public health policy.

My friend’s Huff Post blog on cervical mucus has garnered 26,000 likes and 3,049 shares. Women have written from all over the world to thank her for this information. Despite our best efforts as sex educators, although we have been teaching specifics about female fertility for decades, it still seems to remains a mystery – not only to those who want to plan a pregnancy – but also to those who are trying to use their knowledge of fertility as a method of contraception. With the operative word being “trying”.

Yet, clearly Canadians are using some form of birth control, because the age of first pregnancy is continually rising. According to a report by Statistics Canada “the switch happened in 2010 and widened in 2011, when there were 52.3 babies born per 1,000 women ages 35 to 39 and 45.7 per 1,000 women ages 20 to 24… birth rates for women in their early 40s now are nearly as high as for teens.”

Young adults are trying to figure out how to succeed at work and somehow “work in” a family to their lives. The most popular methods used by young people today are male condoms, oral contraceptives and withdrawal.

There is no “one size fits all”; but there are some serious considerations – especially for women – before making a choice.

age

number of partners

current health and medical history

how effective the method needs to be

The last point may seem odd, but a woman needs to ask herself how she would feel about being pregnant if her birth control method didn’t work. Some women would accept the pregnancy; others would not. She needs to examine her feelings about abortion as well as its availability.

What works?

Methods that are 98% –99%+ effective:

sterilization

intra uterine system (Mirena IUS)

combined oral contraceptives (the Pill), the Patch or the vaginal ring

Depo Provera (depot medroxyprogesterone acetate)

IUD (copper intrauterine device)

Effectiveness is measured in two ways: perfect use and typical use. For example,

“male condoms are an effective method. However, a man must use a condom correctly from start to finish. With perfect use, 2 women out of 100 would get pregnant (98%); but with typical use, 15 would get pregnant (85%)”.

Withdrawal, the third most common method used by young people must also be used carefully. An inexperienced man may find that its effectiveness drops as his desire to stay inside increases.

What my friend has written about fertile mucus comes in very handy when using withdrawal or condoms. If a man does not pull out in time and his partner is at the most fertile time in her cycle, she needs to consider using emergency contraception. The same advice holds true for a condom that breaks.

“Ask a woman if she is using birth control and she will likely tell you whether or not she is taking “the pill.” For most women, they are synonymous. Often, she’ll ask her doctor to ‘put’ her on the birth control pill, which conjures the image of a five-minute consultation, prescription pad at the ready. Do the words “informed consent” have any real meaning when it comes to birth control?”

Sadly, pharmaceutical companies skip through the loophole in Canadian laws prohibiting direct to consumer advertising in order to sell hormonal contraceptives, especially the pill. But safety is an issue. There is a difference between side effects and risks. As I point out, some hormonal methods and formulations are riskier than others.

This leaves some people wondering about alternatives.

Unfortunately, there isn’t much that’s new on the contraceptive scene. A few methods are in clinical trials, but nothing that really changes the birth control landscape.

But perhaps youngish women should not practise contraception too long if they want to have a baby “some day” given the decline in fertility after 35. As a young friend said to me recently, “Just assume that all my friends who are rapidly approaching 40 are trying.”